Session Note Template:
For use by a clinician using a Cognitive Behavioural Therapy for Insomnia (CBT-I) framework, this template provides a detailed summary of a session with a client recorded on or uploaded to NovoNote.
Template Structure
Example Output
Template Structure
Presenting concerns and sleep status update:
Describe the client’s self-reported sleep patterns since the last session, including sleep onset latency, nocturnal awakenings, early morning awakenings, total sleep time, sleep efficiency, subjective sleep quality, daytime functioning, and any significant changes or stressors affecting sleep.
Review of previous session and homework compliance:
Describe key topics from the last session, client’s adherence to previously assigned strategies, challenges encountered in implementation, and insights or improvements noted by the client.
Session focus and interventions:
- Psychoeducation: Describe education provided on sleep homeostasis, circadian rhythms, sleep drive, and cognitive/behavioural factors affecting sleep, including explanations of treatment components.
- Cognitive interventions: Describe identification and restructuring of unhelpful thoughts about sleep and reframing of sleep-related beliefs discussed with the client.
- Behavioural interventions: Describe sleep restriction therapy, stimulus control strategies, relaxation and mindfulness techniques, sleep hygiene modifications, and addressing unhelpful daytime behaviours discussed with the client.
- List specific homework assigned (sleep diary, stimulus control strategies, cognitive restructuring)
- Describe goals for the next session
- Detail plans for overcoming anticipated barriers
Example Output
Presenting concerns and sleep status update:
- Sleep onset latency reduced from 65 to 45 minutes. Client experiences 2-3 awakenings nightly (50 minutes total) and early morning awakening at 4:30am three times this week. Sleep efficiency improved to 72% from 65%, with average sleep time of 5.5 hours. Continued daytime fatigue and concentration difficulties reported.
- Work deadline causing increased worry about sleep impact.
- Successfully eliminated caffeine after 12pm.
- Good adherence to stimulus control, consistently leaving bed when awake over 20 minutes.
- Sleep window (11:30pm-5:30am) followed 5/7 nights, with two instances of oversleeping due to fatigue.
- Sleep diary completed with good detail, noting reduced anxiety on nights following exercise.
- Psychoeducation: Discussed sleep efficiency as treatment progress metric. Explained temporary increase in daytime fatigue during initial sleep restriction. Emphasised importance of consistency in sleep schedule for circadian rhythm entrainment.
- Cognitive interventions:
- Addressed catastrophic thinking about work presentation (“If I don’t sleep enough, I’ll completely fail”).
- Explored perfectionistic beliefs about needing 8 hours of sleep.
- Developed more balanced thought: “I’ve managed important tasks with less sleep before, and can cope adequately.”
- Behavioural interventions:
- Adjusted sleep window to 11:15pm-5:45am based on improved efficiency.
- Reinforced consistent wake time regardless of sleep quality. Introduced diaphragmatic breathing for pre-bedtime relaxation.
- Recommended clock removal during night to prevent checking behaviour.
- Suggested brief walk instead of caffeine for afternoon energy dip.
- Continue sleep diary with adjusted window (11:15pm-5:45am)
- Practice diaphragmatic breathing for 5 minutes before bed nightly
- Implement clock removal/facing away during sleep period
- Record sleep-related worries and practice cognitive restructuring
- Test prediction about function after poor sleep by noting actual vs. predicted performance
- Template Type
- Session Note
- Note Dictation
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